Provider Demographics
NPI:1407410970
Name:QUEDENFELD, STACIE (APRN)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:QUEDENFELD
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7620 LAKE UNDERHILL RD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32822-8223
Mailing Address - Country:US
Mailing Address - Phone:321-235-0692
Mailing Address - Fax:321-235-0694
Practice Address - Street 1:7620 LAKE UNDERHILL RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32822-8223
Practice Address - Country:US
Practice Address - Phone:321-235-0692
Practice Address - Fax:321-235-0694
Is Sole Proprietor?:No
Enumeration Date:2019-04-30
Last Update Date:2021-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11002198207Q00000X
FLAPRN11002198363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAPRN11002198OtherFLORIDA LICENSE